Pemicu 7

Margaret Melvi
405120212
S Adanya penurunan daya dengar, kadang disertai tinitus (biasa terjadi pada orang tua dan
simetris)
O Anamnesis, Pure tone audiogram, bila terjadi penurunan pendengaran asimetris MRI
untuk singkirkan kemungkinan vestibular schwanoma
A Presbiakusis: onset paruh baya sampai usia lanjut, bilateral, hilang pendengran
sensorineural progresif, di mana penyebab yang mendasari tidak ada (telah disingkirkan)
P Konseling, perubahan lingkungan ( kurangi bising, memakai tanda lain seperti flash light
sebagai ganti bel pintu, dsb.), belajar membaca gerak bibir, penggunaan alat bantu
dengar

Scott-Brown 7th edition Ch. 238a

S Pendengaran tidak jelas biasanya bilateral, kalau nonton TV suara lebih keras, percakapa dgn telepon
terganggu, adanya hiperakusis, adanya riwayat terpajan suara bising yang keras, kadang ada tinitus
O Pure tone audiogram, audiometri, timpanometri, MRI (jika asimetris dan beda 10 dB pada frekuensi
yg sama)
A Noise-induced hearing loss penurunan daya dengar akibat pajanan suara bising yg keras, dapat
terjadi pergeseran ambang pendengaran sementara maupun menetap
P Kurangi terpapar suara bising, gunakan pelindung telinga, secara umum hampir sama dengan
presbiakusis

S Adanya penurunan daya dengar (baik konduktif maupun sensorineural) bisa unilateral maupun
bilateral
O Anamnesis, Otoskopi (Schwartz sign), diagnosis dgn bedah (terlihat alas kaki stapes terlihat lebih
tebal), diagnosis histologi (hanya jika stapedectomy total dilakukan), pure tone audiometry (adanya
air-bone gap), timpanometri, CT (u/ menilai densitas tulang)
A Otosklerosis:
• Clinical  lesi pada tulang stapes atau hubungan stapediovestibular tuli konduktif
• Histologic lesi tidak pada tulang stapes, hubungan stapediovestibular, atau endosteum koklea,
biasanya asimtomatik dan dapat didiagnosis hanya dgn post-morterm examination pada tulang
temporal.
• Cochlear tuli sensorineural murni karena otosklerosis tanpa adanya kelainan konduktif lainnya.
P Alat bantu dengar komersial maupun Bone anchored hearing aid (yg dikaitkan di tulang

Scott-Brown 7th edition Ch.238b

Scott-Brown 7th edition Ch. 237e
Ballenger 17th edition ch. 20
S Merasa seperti berputar (vertigo), Sulit untuk fokus, Otalgia, Otore, Pusing, Gangguan pendengaran di
satu telinga, Kehilangan keseimbangan, Mual muntah, Tinitus
O • EEG
• Electronystamography
• Audiologi/audiometri
Viral labyrinthitis sensorineural hearing loss
Suppurative labyrinthitis unilateral hearing loss
Serous labyrinthitis  unilateral, high-frequency hearing loss in the affected ear. A conductive loss in
the same ear may occur secondary to effusion.
• CT-Scan kepala/ MRI kepala
A Labirintitis Iritasi dan pembengkakan pada telinga dalam
Et: virus (Rubella, CMV)/ bakteri (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella
catarrhalis) infeksi telinga
Pemicu : Flu, alergi
P • Antihistamin
• Obat-obatan untuk mengontrol mual dan muntah, seperti proklorperazin (Compazine)
• Obat meredakan pusing, seperti meclizine (Bonine, Dramamine, atau Antivert) atau skopolamin
(Transderm-Scop)
• Sedatif, seperti diazepam (Valium)
• Steroid (Prednison)
• Antivirus
• Istirahat
• Hindari gerakan tiba-tiba atau perubahan posisi

https://www.nlm.nih.gov/medlineplus/ency/article/001054.htm
http://emedicine.medscape.com/article/856215-workup#c8
S Obstruksi nasal, Epistaksis, Sakit kepala, Pembengkakan wajah, Nasal mass, Orbital mass,
Proptosis
O Radiologi, Angiografi
A Juvenile Nasopharyngeal Angiofibroma
• Tumor fibrovascular nonecapsulated yang timbul di wilayah foramen sphenopalatina
• Jinak tp dapat menunjukkan pola pertumbuhan agressif melalui foramina atau fissura
• Tumor ini cenderung berdarah deras  pasien datang dengan epistaksis
P • Preoperative embolization
• Hormonal Therapy
• Surgical Therapy

S Epitaksis, hidung buntu, kadang ada OME akibat tertutupnya TE, kadang disertai nyeri kepala, nyeri
pada daerah mata, nyeri daerah wajah (atau paralisis), dan disfagia *akibat perjalaran dan penekanan
tumor pada saraf kranial
O MRI dan CT (MRI lebih baik untuk membedakan jaringan lunak dan tumor sedangkan CT lebih baik
untuk menilai erosi tulang akibat desakan tumor)
A NPC
Faktor risiko: infeksi EBV, konsumsi makanan tinggi garam, merokok, konsumsi alkohol berlebih,
terpapar formalin dan debu kayu (sehubungan dengan pekerjaan)
P Operasi jarang dilakukan, radioterapi lebih sering dilakukan

Scott-Brown 7th edition volume 3 pg. 3954

http://emedicine.medscape.com/article/872580-overview#showall
Ballenger 17th edition ch. 96
S Postural imbalance, Visual instability, Nausea, vomiting, Figure 240c.2 The responses of a normal
Nystagmus, Ocular tilt reaction healthy subject ((a) to (e)) and a patient
with right-sided vestibular loss ((d) to (f))
to the
O - head impulse test are illustrated. In both
cases, the subject's head is rapidly
A Vertigo ilusi gerakan rotasi dikarenakan aktivitas nucleus rotated towards the right. Before the
head rotation ((a)
vestibula yg asimetris and (d)), the subject is instructed to look
at the examiner's nose and to try not to
blink. During the head rotation, the eyes
P • Vestibular rehabilitation theray of the
healthy subject stay fixed on the
• Antihistamines (cyclizine & cinnarizine) examiner's nose (b) and remain so at the

• Prochlorperazine end of the head rotation (e), so that no

re-fixation is
necessary. In the patient with unilateral
vestibular loss, during rotation of the
head towards the affected side, the VOR
is deficient and
cannot move the eyes to compensate for
the head rotation, so that the eyes move
in the same direction as the head (i.e. to
the right)
(e). At the end of the head rotation, the
eyes have been dragged off target and so
a corrective saccade is required ((f),
arrowheads) to
re-fixate the examiner's nose. If the
patient's head and eye rotations are
recorded using the magnetic search coil
technique ((g) and
(h), grey and black traces respectively),
the lack of a compensatory eye
movement response during rightward
(ipsilesional) head
impulses clearly contrasts with the
almost normal response during leftward
(contralesionai) head impulses. Figures
(g) and (h) courtesy
of ST Aw, Sydney, Australia.

Scott-Brown 7th edition ch. 240c

http://www.nhs.uk/Conditions/Vertigo/Pages/Treatment.aspx
 S riwayat episode singkat vertigo , Mual,
Muntah, Nystagmus

O MRI

A Benign Paroxysymal Positioning Vertigo

gangguan yg ditandai dengan serangan
singkat vertigo, nystagmus, dipicu oleh
perubahan tertentu posisi kepala
sehubungan dengan gravitasi.

P Epley Manuver

Figure 240c.10 The Epley particle repositioning manoeuvre for left posterior SCC
BPPV. The patient is rapidly reclined into the left
Dix-Hallpike position (a) and remains in that position until both the vertigo and
nystagmus have totally disappeared and the otoconial
particles have settled into the lowest portion of the posterior SCC duct. The
patient's head is slowly turned by 90° into the right
Dix-Hallpike position (b-f) , so that the particles are guided into the crus
communis. Then the patient slowly rolls on to the right
shoulder (g) and the head is turned another 90° so that the particles fall via the
crus communis back into the vestibule. The
manoeuvre is completed by sitting the patient upright. Adapted from Halmagyi
GM, Cremer PD. Assessment and treatment of dizziness.
Journal of Neurology, Neurosurgery, and Psychiatry. 2000; 68: 129-36.

Scott-Brown 7th edition ch. 240c

S Two or more spontaneous attacks of vertigo, Hearing loss, Tinnitus, Aural fullness
O Electrocochleography
A Menierre disease Etiologi: Idiopathic, Overproduction or malabsorption endolymph,
Periodic ruptures of membranous labyrinth, Syphilis, mumps, Cogan’s syndrome,
trauma, chronic suppurative otitis media  Meniere’s syndrom
Phase of the attacks:
Irrritative phase
Horizontal/horizontal-torsional nystagmus, beats towards the affected
ear (last < 1 hour)
Paretic phase
Nystagmus beats away from the affected ear (several hours – 1 or 2
days)
 peripheral hypofunction  spontaneous neural activity in the
right vestibular nucleus is <  nystagmus beats toward the left ear
Recovery phase
Nystagmus beats towards the affected ear again (last like the 2nd phase)
P • Diuretics
• Surgery Endolymphatic sac surgery, Vestibular neurectomy, Labyrinthectom
• Hearing aids
• Systemic aminoglycosides (streptomycin & gentamycin)

Scott-Brown 7th edition ch. 240c

S Sudden onset vertigo (lasting days to weeks), nausea, and emesis, Spontaneous
nystagmus -> beats toward the nonaffected ear, Postural imbalance
O PF:
Nystagmus
Weber test : unilateral loss of hearing
Rinne test : sensorineural/conductive
ENG/VNG : unilateral vestibular hypofunction
Imaging :
CT-scan & MRI
A Vestibular neuritis Disorder that affect superior division of vestibular nerve
Etiology :
Inflammation
Ischemia of the labyrinth
HSV-1
P Supportive :
Hydrated
Antiemesis
Vestibular suppressants :
Meclizine
Low dose valium 2mg/6hr
Corticosteroid

Ballenger's 17th edition ch. 28

S

O Anamnesis
A Motion sickness
P Adults :
Antihistamine
Cyclizine
Dimenhydrinate
Meclizine
Promethazine
Metocloperamide
Children
dimenhydrinate 1–1.5 mg/kg per dose
diphenhydramine 0.5–1 mg/kg per dose up to 25 mg
given 1 hour before travel and every 6 hours during the trip
Scott-Brown 7th edition ch. 230
http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/motion-sickness
S • Rinore (rhinitis non-alergi) selama bbrp tahun, lalu terjadi sumbatan hidung yg bertahap, kemudian persisten
dan sekret menjadi lbh kental
• Berkurangnya kemampuan menghidu dan pengecapan
• Gejala dpt dipicu oleh iritan yg terhirup, bbrp makanan atau minuman beralkohol
• Timbul rhinitis, eksaserbasi asma, gatal pada kulit atau urtikaria setelah bbrp menit-jam mengkonsumsi NSAID
(NSAID intolerance)
O Pada anak-anak : frog nose

- Rhinoskopi : utk polip besar

- Endoskopi :
• Utk diagnosis, follow up setelah terapi, dan staging
• dilakukan setelah pemberian anestesi lokal dan vasokonstriktor dgn spray pada hidung

Imaging :
- CT scan hidung & sinus paranasal : dilakukan jika curiga adanya keganasan atau meningokel (terutama jika polip
unilateral, hidung berdarah dan nyeri), sebelum pembendahan dgn endoskopi, dan dpt juga untuk staging
A Polip Nasal
P • Kortikosteroid intranasal
- long-term
- utk kasus ringan atau berat
(dengan terapi tambahan di
bawah)
• Kortikosteroid sistemik (2-3 minggu)

• Pembedahan (jika sumbatan hidung berat) :

- Simple polypectomy
- Endoscopic surgery (untuk
kasus yg berat & persisten)
Scott-Brown 7th edition ch. 121
S Adanya gangguan pendengaran atau naiknya ambang pendegaran pada salah satu telinga
atau keduanya disertai riwayat trauma tumpul pada daerah kepala terutama sekitar telinga
O • Pada PF ditemukan adanya bukti penetrasi trauma pada regio temporal: otorrhea,
memar sekitar proc. mastoideus (Battle’s sign) atau adanya kelumpuhan pada lower
motor neuron nervus facialis.
• Pada otoskopi dapat ditemukan darah segar pada meatus auditori eksternal, bukti
trauma pada membran timpani berupa perforasi, hemotimpanum, atau deformitas
tulang pada meatus auditori eksternus
• CT merupakan gold standar  ada tidaknya fraktur temporal, namun hemotimpanum
saja sudah menjadi nilai prediktif positif
• MRI dapat memberika bukti adanya trauma pada nervus facialis dan hematoma pada
koklea
• Hearing assessment dan vestibular assessment
• Pemeriksaan nervus facialis
• Pemeriksaan kebocoran CSF (cairan otorrhea dikirim untuk dilakukan beta-2 transferrin
analysis
A Temporal bone trauma  adanya trauma fisik pada atulang temporal akibat hantaman
pada permukaan maupun penetrasi peluru. Hal ini dapat dgn atau tanpa fraktur tulang
temporal
P observasi

Scott Brown 7th edition ch.237g

S Pain, increasing with depth
O Canal skin & tympanic membrane  injected, petechial hemorrhage, bleeding
A External ear barotrauma  external ear squeeze, reversed ear, reverse eae squeeze
• e/  earplugs, cerumen foreign bodies, exostoses, tight fitting diving hood
P Immediate decompress by ascending
Meatus should be kept dry
Diving avoided until the skin appears normal
Occlusive ear plugs avoided (diving > 1,5 m & when flying)

S • Blocked ear with strong desire to equalize

• Otalgia  worsens with increased compression & the inability to equalize the
middle ear pressure
• Sudden severe pain  perforation
O • Conductive hearing lose because ossicular damage
• Tympanic membrane  normal appearance to free hemorrhage + perforation
A Middle ear barotrauma 
barotitis media, middle ear squeeze
P • Symptoms but no sign  no treatment
• Symptoms & sign, no perforation  oral/topical nasal decongestan
• Perforation  initial observation + cleaning of the affected ear
• Prevention  oral decongestan, nasal baloon inflation, myringotomies
Scott Brown 7th edition ch. 237g
S
O • Tympanometry in conjunction electronystagmography
• Electrocochleography with tone-burst stimuli
• High definiton MRI & CT  promising investigations
A Inner ear barotrauma (Histopathological)
P Surgical result are good for vestibular symptoms & relatively poor
for hearing imparment. 
• Early surgery
• Steroids for moderate & severe hearing losses
Prevention scuba diving contraindicated if persistent problems,
decongestants before flying/diving

Scott Brown 7th edition ch. 237g

S • Transient or minimal • Vertigo • Transient dysequilibrium
vestibular symptoms • tinnitus & dizziness
• Mild to moderate • hearing loss (often at 1- • Difficulty equalizing the
sensorineural hearing 2kHz which is permanent) middle ear pressure
loss • Sudden onset of vertigo,
sensorineural hearing loss,
tinnitus
• Nystagmus usually
towards the opposite side
O A good recovery would be • Temporal bone studies • Dysequilibrium which
expected  reissner’s membrane worsen / changes to
rupture momentary vertigo when
• Inner ear damage  performing manoeuvres
• Hemorrhage around which increase the
reissner’s & the intracranial pressure
round window
membrane
• Rupture of the utricle
& saccule
A inner ear haemorrhage; labyrinthine membrane perilymphatic fistula.
tears;
P
Scott Brown 7th edition ch. 237g
 Figure 237g.4 Otitic barotrauma on
descent: theoretical pressure changes
(kPa) and potential pathology. (a) Equal
pressures on
surface (sea level). Actual inner ear
perilymph pressure is really slightly
higher than ambient pressure. (b)
Normal equalization with
descent. (c) Depth 0.86 m and pressure
difference of 8 kPa, bulging tympanic
membrane and round window into
middle ear. (d-f)
blocked and locked Eustachian tube. (d)
1.29 m with 12 kPa pressure difference.
(e) Tympanic membrane ruptures at
variable pressures.
(f) Forced Valsalva increases CSF and
perilymph pressure resulting in round
window rupture. Adapted with
permission from Farmer JC,
Thomas WG. Ear and sinus problems in
diving. In: Strauss R (ed.). Diving
medicine. New York: Grune and Stratton,
1976.

Scott Brown 7th edition ch. 237g

 Pathophysiology
• Diver menyelam  perbedaan tekanan di luar dan
dalam telinga  penyesuaian tekanan melalui
tuba Eustachius (by the voluntary action of the
tensor and levator palati muscles opening )  bila
gagal  membran timpani terdorong ke dalam 
sensation of external pressure and discomfort 
diver kembali ke permukaan  bila masih tetap
gagal menyesuaikan tekanan  Middle Ear
Barotrauma  udem & kongesti mukosa
• If the pressure gradient across the tympanic membrane is large ,then the
tympanic membrane may rupture.
• Otalgia can develop in as little as 3 ft of water.
• Eustachian tube can be entirely dysfuntional and locked at 4 ft.
• If the pressure differential is not relieved, TM rupture can occur within 5 ft of
the surface.
S Conductive hearing loss
* hearing loss may be due to ossicular chain disruption or middle
ear haemorrhage
O Audiometry, Tympanometry
A Ossicular chain trauma
A conductive hearing impairment that persist following head
trauma is most likely due to incus dislocation

Types of trauma:
Injuries to the ossicular chain  result from head injury
Direct trauma including surgery or lightning
P Surgery:
• Conventional ossiculoplasty techniques or repositioning of the
incus.
• Malleus handle fractures  using small bone grafts.
• Stapes luxation  stapedectomy
Scott Brown 7th edition ch. 236m
S Adanya riwayat trauma, memar yg tidak nyeri dengan inflamasi minimal. Umumnya sehubungan
dengan aktivitas olahraga (gulat, rugby)
O • Anamnesis
• PF
A Hematomal auris  terkumpulnya darah di antara kartilago aurikular dan perikondrium. Kumpulan
darah tersebut akibat adanya trauma atau kadang ruptur mendadak pembuluh darah.
P Evakuasi perdarahan secara asepsis ketat (supaya tidak terjadi infeksi) dengan aspirasi (needle) atau
jika tidak adekuat dapat dilakukan insisi.

S Hilangnya kemampuan untuk mendengar suara di satu atau kedua telinga

O Anamnesis,otoskopi,audiometry,MRI/ct scan
A Konduktif hearing loss : karena adanya maechanical problem di bagian telinga luar dan tengah

Sensorineural hearing loss : karena adanya kerusakan saraf dan bagian telinga dalam

Mixed hearing loss : kerusakan pada bagian telinga luar/tengah dan telinga dalam (campuran tuli
konduktif dan sensorineural)
P -Membersihkan telinga dengan baik dan benar
-Pelunak wax bila susah dibersihkan
-Operasi : eardrum repair,tube di eardrum untuk mngeluarkan cairan ,ossiculoplasty (repair
tulang kecil di dalam telinga)
-Hearing aid

Scott Brown 7th edition ch. 236m

https://www.nlm.nih.gov/medlineplus/ency/article/003044.htm